Why do Patients Forget to Take Immunosuppression Medications and Miss Appointments: Can a Mobile Phone App Help?

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Abstract

Background

Kidney transplant recipients must adhere to their immunosuppressive medication regimen. However, non-adherence remains a major problem.

Objective

The aim of this paper is to determine how kidney transplant recipients remember to take their medications, and assess their perception and beliefs about adherence to immunosuppressive medications and barriers to medication adherence. In addition, we aim to assess perception and beliefs about willingness to use a hypothetical, mobile phone app to improve adherence.

Methods

We conducted a qualitative study that included an average of three home or workplace visits of kidney transplant recipients (N=16) from a single urban transplant center.

Results

The qualitative study revealed that transplant recipients understood the importance of taking their immunosuppressive medications and this motivated them to take their medications. The visits showed that most participants have incorporated medication use into their daily lives and that any minor deviation from daily routines could result in non-adherence. Participants also reported other barriers to adherence. All participants were interested in using an app to remind them to take their medication; however, they reported potential barriers to using the app.

Conclusions

Although kidney transplant recipients understood the importance of medication adherence, there were significant barriers to maintaining adherence. Participants also reported interest in using a mobile phone app.

Related collections

Most cited references 27

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Social learning theory and the Health Belief Model.

Amy Becker, Victor Strecher, I Rosenstock (1987)

The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is conceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory factors may be related, and in so doing, posits a revised explanatory model which incorporates self-efficacy into the Health Belief Model. Specifically, self-efficacy is proposed as a separate independent variable along with the traditional health belief variables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.

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Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review.

Paul Roderick, Mark Mullee, Robert Peveler … (2004)

Nonadherence to immunosuppressants is recognized to occur after renal transplantation, but the size of its impact on transplant survival is not known. A systematic literature search identified 325 studies (in 324 articles) published from 1980 to 2001 reporting the frequency and impact of nonadherence in adult renal transplant recipients. Thirty-six studies meeting the inclusion criteria for further review were grouped into cross-sectional and cohort studies and case series. Meta-analysis was used to estimate the size of the impact of nonadherence on graft failure. Only two studies measured adherence using electronic monitoring, which is currently thought to be the most accurate measure. Cross-sectional studies (n=15) tended to rely on self-report questionnaires, but these were poorly described; a median (interquartile range) of 22% (18%-26%) of recipients were nonadherent. Cohort studies (n=10) indicated that nonadherence contributes substantially to graft loss; a median (interquartile range) of 36% (14%-65%) of graft losses were associated with prior nonadherence. Meta-analysis of these studies showed that the odds of graft failure increased sevenfold (95% confidence interval, 4%-12%) in nonadherent subjects compared with adherent subjects. Standardized methods of assessing adherence in clinical populations need to be developed, and future studies should attempt to identify the level of adherence that increases the risk of graft failure. However, this review shows nonadherence to be common and to have a large impact on transplant survival. Therefore, significant improvements in graft survival could be expected from effective interventions to improve adherence.

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Is Open Access

Mobile Health Medication Adherence and Blood Pressure Control in Renal Transplant Recipients: A Proof-of-Concept Randomized Controlled Trial

John W McGillicuddy, Mathew J Gregoski, Anna K Weiland … (2013)

Background Mobile phone based programs for kidney transplant recipients are promising tools for improving long-term graft outcomes and better managing comorbidities (eg, hypertension, diabetes). These tools provide an easy to use self-management framework allowing optimal medication adherence that is guided by the patients’ physiological data. This technology is also relatively inexpensive, has an intuitive interface, and provides the capability for real-time personalized feedback to help motivate patient self-efficacy. Automated summary reports of patients’ adherence and blood pressure can easily be uploaded to providers’ networks helping reduce clinical inertia by reducing regimen alteration time. Objective The aim of this study was to assess the feasibility, acceptability, and preliminary outcomes of a prototype mobile health (mHealth) medication and blood pressure (BP) self-management system for kidney transplant patients with uncontrolled hypertension. Methods A smartphone enabled medication adherence and BP self-management system was developed using a patient and provider centered design. The development framework utilized self-determination theory with iterative stages that were guided and refined based on patient/provider feedback. A 3-month proof-of-concept randomized controlled trial was conducted in 20 hypertensive kidney transplant patients identified as non-adherent to their current medication regimen based on a month long screening using an electronic medication tray. Participants randomized to the mHealth intervention had the reminder functions of their electronic medication tray enabled and received a bluetooth capable BP monitor and a smartphone that received and transmitted encrypted physiological data and delivered reminders to measure BP using text messaging. Controls received standard of care and their adherence continued to be monitored with the medication tray reminders turned off. Providers received weekly summary reports of patient medication adherence and BP readings. Results Participation and retention rates were 41/55 (75%) and 31/34 (91%), respectively. The prototype system appears to be safe, highly acceptable, and useful to patients and providers. Compared to the standard care control group (SC), the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations. Physicians made more anti-hypertensive medication adjustments in the mHealth group versus the standard care group (7 adjustments in 5 patients versus 3 adjustments in 3 patients) during the 3-month trial based on the information provided in the weekly reports. Conclusions These data support the acceptability and feasibility of the prototype mHealth system. Further trials with larger sample sizes and additional biomarkers (eg, whole blood medication levels) are needed to examine efficacy and effectiveness of the system for improving medication adherence and blood pressure control after kidney transplantation over longer time periods. Trial Registration Clinicaltrials.gov NCT01859273; http://clinicaltrials.gov/ct2/show/NCT01859273 (Archived by WebCite at http://www.webcitation.org/6IqfCa3A3).

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Author and article information

Contributors

Ajay Israni:

Hennepin County Medical CenterDepartment of Medicine701 Park AveMinneapolis, MN, 55415United States1 612 873 69871 612 873 1655isran001@umn.edu

ORCID: http://orcid.org/0000-0002-7607-0430

Journal

Journal ID (nlm-ta): JMIR Public Health Surveill

Journal ID (iso-abbrev): JMIR Public Health Surveill

Journal ID (publisher-id): JPH

Title: JMIR Public Health and Surveillance

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Electronic): 2369-2960

Publication date Collection: Jan-Jun 2016

Publication date (Electronic): 04 April 2016

Volume: 2

Issue: 1

Electronic Location Identifier: e15

Affiliations

[1] ¹Hennepin County Medical Center Department of Medicine Minneapolis, MNUnited States

[2] ²University of Minnesota Department of Epidemiology and community Health Minneapolis, MNUnited States

[3] ³Minneapolis Medical Research Foundation Minneapolis, MNUnited States

[4] ⁴University of Minnesota Department of Renal Diseases and Hypertension Minneapolis, MNUnited States

[5] ⁵Center for Policy, Outcomes and Prevention and Division of General Pediatrics Stanford University School of Medicine Palo Alto, CAUnited States

Author notes

Corresponding Author: Ajay Israni isran001@ 123456umn.edu

Author information

Ajay Israni http://orcid.org/0000-0002-7607-0430

Carl Dean http://orcid.org/0000-0002-2266-951X

Brian Kasel http://orcid.org/0000-0003-4678-1124

Lisa Berndt http://orcid.org/0000-0001-9720-5456

Winston Wildebush http://orcid.org/0000-0002-6164-9562

C Jason Wang http://orcid.org/0000-0002-6278-4889

Article

Publisher ID: v2i1e15

DOI: 10.2196/publichealth.5285

PMC ID: 4869221

PubMed ID: 27227150

SO-VID: 55d4a670-a209-4d1b-964d-f34e0162d9c3

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license information must be included.

History

Date received : 26 October 2015

Date revision requested : 1 December 2015

Date revision received : 14 December 2015

Date accepted : 14 December 2015

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